As laser vaginal rejuvenation (LVR) procedures continue to become more accepted and popularized in the media, PSP spoke with one of its leading practitioners, Marco A. Pelosi II, MD, FACOG, FACS, FICS, director of the family-run Pelosi Medical Center in Bayonne, NJ, to offer his thoughts on LVR and its growth in cosmetic surgery practices.

Pelosi is author (or coauthor) of numerous papers on LVR techniques. In these publications and lectures, he demonstrates laparoscopic and vaginal techniques for the routine removal of large uteri, urogynecologic procedures, and rectovaginal surgery. The Pelosis are also known for the American introduction of the transobturator sling technique for the treatment of stress urinary incontinence.

In 2004, he and Marco A. Pelosi, III, created cosmetogynecology as a new subspecialty for OB/GYNs to provide their patients comprehensive nonsurgical and surgical cosmetic treatments for beautification, rejuvenation, and sexual enhancement. The same year, they founded the International Society of Cosmetogynecology (ISCG), an association of 3,800 OB/GYN specialists in nonsurgical and surgical cosmetic procedures.

PSP: Describe how the demand for vaginal rejuvenation and labiaplasty has recently grown in popularity.

Pelosi: Cosmetic or aesthetic vaginal surgery is not a new phenomenon. Papers about genital surgical alterations performed for purely cosmetic reasons were published as early as 1984.1 Awareness of cosmetic vaginal surgery has been growing for the past few years, but the pace has accelerated recently due in part to media coverage, focused attention from medical and surgical specialty societies, and the growing number of women who have undergone these procedures.

We are presently receiving three times as many inquiries for this surgery than we did last year. The demographics have changed, as well. We have noticed a great increase in the number of “soccer moms” requesting these procedures and also an increase in referrals from physicians in other specialties.

PSP: Has this trend been in the works for a long time and nobody talked about it, or is the trend new? Why is it taking off now?

Pelosi: Ten years ago David Matlock in California, the Pelosi group in the greater New York area, John Miklos and Robert Moore in Atlanta, and a handful of surgeons in other areas of the country and throughout the world were the only centers performing this type of surgery routinely. The desire was definitely there among women from all walks of life, but access to such services was limited geographically, and many women who wanted this type of surgery simply could not afford to travel long distances. It was an expensive proposition.

At the same time, the subject was considered taboo in traditional medical and surgical circles, and surgeons offering these services were considered mavericks at best—or to be exploiting women or manipulating their insecurities.

I think what’s changed over the years is really the expansion of media. Penthouse magazine, Playboy, reality shows, Dr 90210. All of this media attention has created tremendous interest on this subject today.

PSP: How have the techniques and technologies advanced for physicians performing these procedures?

Pelosi: While many of these procedures derive from standard gynecologic operations, the insights and experiences that produce the technical modifications that generate the best aesthetic or functional results are different from standard surgery. To master them, the cosmetic surgeon needs special training.

PSP: Would you comment on the vaginal surgery done for noncosmetic reasons—hymen reattachment for Islamic patients, for example?

Pelosi: There are many medically indicated surgical cosmetic vaginal procedures. They include reversal or repair of female genital cutting, treatment for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions, chronic irritation, or excessive androgenic hormones, the creation of a neo-vagina, or the use of flaps to cover areas secondary to cancer surgery or trauma.

The request for the reconstruction of the hymen or “hymenoplasty” is a unique one. Patients exhibit various reasons for their need, many of them cultural. In some societies, the loss of virginity before marriage is a serious problem that may result in disgrace or even death. These women request the hymenoplasty to preserve the family honor, respect, chastity, marriage ability, and beauty. They want the reassurance that the hymenoplasty will result in tearing and bleeding with the next coitus.

PSP: There seems to be many gynecologists rushing into the cosmetic surgery arena. What are the positives and negatives of this trend?

Figure 1a. Patient with elongated, asymmetric, and hyperpigmented labial tissue requested cosmetic labial reduction. Figure 1b. Appearance of the labia minora 2 weeks following surgery.

Pelosi: With an expanding number of women anxious to undergo cosmetic treatments, an ever-widening variety of cosmetic procedures being introduced to the market, and a highly competitive pool of physicians seeking to gain entry into this market, it makes the addition of cosmetic services to expand the scope of a traditional OB/GYN practice very attractive.

Obstetrician/gynecologists as fully trained surgeons and providers of women’s health primary care are uniquely qualified and positioned to provide cosmetic services. However, the addition of cosmetic services requires that the OB/GYN attain the necessary training and skills, work within an appropriate ethical framework, and offer honest counseling.

Our personal experience reflects this trend. Due to increasing requests by our patients for cosmetic services, we became fully trained in nonsurgical and surgical cosmetic procedures approximately 15 years ago. Since then, [we have been] able to successfully provide a full range of cosmetic services comparable with physicians in other specialties, such as traditional plastic surgeons.

With further training and experience, we were able to attain full hospital privileges to perform cosmetic surgery such as liposuction, breast cosmetic surgery, abdominoplasty, and fat transfer procedures.

PSP: Should there be a more open acceptance of these new doctors entering the field?

Pelosi: For better or for worse, the practice of medicine and surgery continually evolves. The influx of gynecologists into the cosmetic arena is part of a larger influx of physicians from all specialties to aesthetic procedures in response to increasing demand, financial pressure, and technological advances.

Change is inevitable. It is undeniable, and it cannot be wished away by those who reminisce about the past. Gynecologists are uniquely positioned as the only primary care/surgical specialists in the health care industry, and it would behoove any cosmetic surgeon from any other specialty to recognize the value of establishing a positive working relationship with this new cosmetic gatekeeper.

Figure 2a. Appearance of the hyperpigmented, elongated, and asymmetric labia minora. Figure 2b. Appearance of the labia minora 4 weeks following surgery.

PSP: What is your opinion of the objections from other surgeons who complain that noncore physicians are not as well trained or trained adequately to advertise surgical procedures or cosmetic surgery?

Pelosi: Cosmetic surgery is and always has been a discipline with roots in many surgical specialties, with influences from some medical subspecialties. However, no residency program in any specialty produces cosmetic surgeons, since the focus of a surgical specialty-training program is the profit potential that exists from excluding competition. There will always be a strong and undeniable financial motive behind many of the complaints about competitors, as well as whether or not some specialists are more qualified to learn many of the commonly requested cosmetic surgical procedures and to manage their complications.

Problems arise when a few bad apples from any camp bypass the learning process or take shortcuts that compromise quality or safety.

Our experience in training over 3,000 OB/GYN specialists has confirmed that they can easily incorporate their surgical skills and expertise in managing cosmetic procedures in a safe and effective manner. The society offers monthly preceptorships and mini-fellowships in cosmetic surgery, and an annual international meeting in association with the American Academy of Cosmetic Surgery.

PSP: What is your response to those who say that LVR is unethical and medically unnecessary?

Pelosi: It is well established that the performance of cosmetic procedures—such as liposuction, breast cosmetic surgery, abdominoplasty, facelifts, rhinoplasty, etc—are patient-choice elective, ethical procedures, and no one is claiming that they are medically indicated. Aesthetic vaginal surgery falls into the same category. There is no valid reason to deny women this right.

At the present time, there seems to exist a double standard. Critics claim that vaginal cosmetic surgery is not medically indicated, and they consider the surgery to be “unethical.” They stress the lack of data to show that the procedures are safe or effective, and they stress that there are no randomized controlled trials. Some even suggest that a women considering vaginal cosmetic surgery should first have a full psychological evaluation.

Figure 3a. 48-year-old patient requested vaginal tightening and labia minora reduction. Notice the patulous vagina. Figure 3b. Appearance of the genitalia 6 weeks following surgery.

It is of interest to note that none of the same critics object to the other cosmetic procedures or attack cosmetic surgeons suggesting that their practices are unethical, that their procedures are not medically indicated, that they do not have randomized controlled trials, and that their patients should all be sent to a psychologist before having a facelift, tummy tuck, rhinoplasty, liposuction, or breast implants.

It is obvious that these critics do not understand that cosmetic vaginal procedures are purely aesthetic, and that no claims are made regarding outcome other than meeting the patient’s desire and expectations. The most important end point is patient satisfaction. It is unfortunate that cosmetic vaginal procedures are often confused with medically indicated reconstructive plastic surgical procedures performed to improve function and appearance of abnormal body areas.

To suggest that most patients requesting vaginal cosmetic surgery need counseling is paternalistic and demeaning to women. It is of interest to note that a number of feminists who do not approve of vaginal cosmetic surgery demand that women have equal rights and freedom, yet then they doubt a woman’s ability to make an informed decision for herself when she seeks aesthetic vaginal surgery.

PSP: What are the most prevalent LVR procedures that you’re seeing today?

Pelosi: A significant number of people have the impression that cosmetic vaginal surgery is represented by two procedures only. The first is the so-called vaginal rejuvenation or vaginal tightening. The goal of the procedure is to restore a firm introital tone. An increasing number of women complain of vaginal “looseness”—or loss of their ability to experience vaginal orgasm after they have had vaginal deliveries—and request tightening of their vagina to regain or enhance vaginal sexual gratification.

The second one is labiaplasty of the labia minora (labial reduction). However, the list of current available procedures for cosmetic enhancement of the female genitalia is more extensive. They include mons pubis liposculpturing and lifting, labia majora volume enhancement with autologous fat transfer or other fillers, labia majora surgical reduction, labia majora midline convergence, labia minora surgical reduction, removal of redundant prepuce, hoodectomy and clitoropexy, vaginal rejuvenation (tightening), hymen restoration, and combinations of procedures.

Not infrequently, women will present with both a cosmetic request such as labia minora reduction and a gynecologic pelvic floor defect, such as urinary stress incontinence. In many instances, the therapeutic and cosmetic surgeries are performed at the same time.

Figure 4a. 44-year-old patient requested vaginal tightening, labia minora, cosmetic reduction, and labia majora volume enhancement. Figure 4b. Appearance of the genitalia 4 weeks after surgery.

The successful performance of cosmetic vaginal surgery requires special training, knowledge of the nomenclature, functional pelvic floor anatomy, and the patient-specific concerns and expectations. The cosmetic vaginal surgeon must be prepared to perform safe and effective functional and aesthetic vaginal surgery.

It is important to emphasize that cosmetic vaginal interventions are not traditional gynecologic procedures or simple modifications. They are new techniques that are customized for each individual patient.

PSP: Where is the practice of vaginal rejuvenation headed? What do you see happening in the future in terms of technologies and treatments?

Pelosi: A variety of procedures are available for cosmetic enhancement of the female genitalia. Despite some current controversy, the types and number of these procedures performed continue to grow. In addition to adequate surgical training, knowledge of sexual medicine is mandatory when operating in patients requesting vaginal rejuvenation/tightening to enhance vaginal sexual gratification—to avoid operating on patients with sexual dysfunction. A comprehensive consent is paramount, and the patient must be aware that the potential beneficial effects on sexual enhancement cannot be guaranteed.

On The Web!

See also "Striving for the Bust" by Connie Jennings in the February 2010 issue of PSP.

At the International Society of Cosmetogynecologists, we are committed to train and preceptor cosmetic surgeons in the field of aesthetic vaginal cosmetic surgery. The society envisions the future cosmetic vaginal surgeon as someone with full expertise in aesthetic vaginal surgery. The physician should be able to correct congenital anomalies of the external genitalia and the creation of neo-vaginas, and have expertise in using vulvovaginal and myocutaneous flaps for correction of defects after cancer surgery, and in correcting deformities, large scars, and vaginal stenosis.

The vaginal cosmetic surgeon should also have expertise in performing transsexual surgery, should be fully capable to use minimally invasive surgical techniques for the performance of complex pelvic surgery, and to carry on combined aesthetic vaginal cosmetic surgery and the treatment of associated pelvic floor defects.


Tor Valenza is associate editor of PSP. He can be reached at [email protected]

REFERENCE

  1. Hodgekinson DJ, Hait G. Aesthetic vaginal labiaplasty. Plast Reconstr Surg. 1984;74:414-416.